APSO NOTE

Patient: [Name]
Date of birth or ID: [Identifier]
Date and setting: [Date; clinic, ward and room, or telehealth]
Note type: [Follow-up, daily progress note, or consult follow-up]
Author: [Name, credentials]

ASSESSMENT
Summary line: [Age, key history, why the patient is here today, and the overall direction: better, unchanged, or worse]
Problem 1: [Diagnosis or working impression, its status today, and the findings below that support it]
Problem 2: [Diagnosis or working impression, status, and supporting findings]
Considered and set aside: [Other diagnoses weighed, and the finding that made each one less likely]

PLAN
Problem 1: [Medication changes with dose and frequency, tests, referrals, and the reason for each]
Problem 2: [Changes, tests, and the reason for each]
Monitoring: [What to recheck, when, and the result that would change the plan]
Discussed with the patient: [Options offered, what was explained, and what the patient chose]
Next contact: [When and how, and the warning signs that mean come back sooner]

SUBJECTIVE
Interval history: [What changed since the last visit or the last note, and since when]
By problem: [Symptoms and pertinent negatives for each numbered problem]
Medications as taken: [Each medication and dose, missed doses, side effects]
Allergies: [Agent and reaction, or none known]

OBJECTIVE
Vital signs: [Today's values, or 24-hour ranges for an inpatient]
Examination: [Focused findings, each labeled with the problem number it supports]
Results: [Labs, imaging, and home readings, with dates and the previous value for comparison]

Author signature: [Name, credentials, date and time signed]